Basic Information
| Provider Information | |||||||||
| NPI: | 1700282589 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROREHAB LOUISVILLE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5629 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477165629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124760409 | ||||||||
| FaxNumber: | 8124761016 | ||||||||
| Practice Location | |||||||||
| Address1: | 6610 BARDSTOWN RD | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402913045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5027621243 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2014 | ||||||||
| LastUpdateDate: | 08/01/2022 | ||||||||
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| AuthorizedOfficialLastName: | BENZ | ||||||||
| AuthorizedOfficialFirstName: | LAURENCE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5027621243 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | K193730 | 01 | KY | MEDICARE | OTHER |